Basic Information
| Provider Information | |||||||||
| NPI: | 1063703809 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LETELLIER | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 SE 164TH AVE DEPT 358 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986838004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607291462 | ||||||||
| FaxNumber: | 3607293104 | ||||||||
| Practice Location | |||||||||
| Address1: | 3301 SQUALICUM PKWY | ||||||||
| Address2: | |||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982251919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607888222 | ||||||||
| FaxNumber: | 3607887759 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2011 | ||||||||
| LastUpdateDate: | 02/20/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD60459476 | WA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0000X | MD60459476 | WA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology | 207RH0003X | MD60459476 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 09028051 | 05 | MS | MEDICAID |